Perforated Merckels Forthcoming-2figure
Perforated Merckels Forthcoming-2figure
Perforated Meckel’s Diverticulum with Acute Appendicitis in an Infant

Tim Jumbi, Shahbal Swaleh, Francis Osawa

School of Medicine, University of Nairobi

Correspondence to: Dr. Tim Jumbi, P.O Box 1059–00618 Ruaraka, Nairobi, Kenya; email: mwaitim@gmail.com

Summary

Meckel’s diverticulum occurs in approximately 2% of the population and is symptomatic in 16% of cases. In children, the most common presentation is intestinal obstruction due to intussusception. The simultaneous occurrence of acute appendicitis and symptomatic Meckel’s diverticulum is rare and when it occurs, it may be associated with non-specific symptoms that present a diagnostic challenge.

 

Keywords: Meckel’s diverticulum, Acute appendicitis

Ann Afr Surg. 2020; 17(1): 42–44.

DOI: http://dx.doi.org/10.4314/aas.v17i11.11

Conflicts of Interest: None

Funding: None

© 2020 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.

Introduction

In 1809 Meckel first reported Meckel’s diverticulum (MD) by describing its embryological origin as a remnant of the omphalomesenteric duct (1). Meckel’s diverticulum is the most common congenital malformation of the gastrointestinal tract with an incidence of between 2% and 4% (2). The occurrence of MD is mostly asymptomatic but is reported to be symptomatic in approximately 16% of cases (3). Symptomatic MD is defined by the presence of gastrointestinal bleeding, intestinal obstruction and peritonitis. The most common presentation in children is intestinal obstruction due to intussusception, with the diverticulum acting as a lead point (4). The simultaneous occurrence of appendicitis and symptomatic MD is rarely seen in adult and pediatric populations. This occurrence may present with non-specific symptoms, which can delay diagnosis and management in these patients. We report the case of a 7-month old admitted with the rare occurrence of a perforated Meckel’s diverticulum and acute appendicitis. This case highlights the rarity and non-specific symptomatology of this occurrence with its diagnostic enigma that can delay intervention in the pediatric population

 

Case Report

We report a case of a 7-month old with a perforated MD and acute appendicitis, with the aim to highlight the symptomatology of this occurrence and its diagnostic enigma which can delay intervention in the pediatric population. A 7-month-old male was admitted to the pediatric surgical unit at Kenyatta National Hospital with a 1-day history of abdominal pain, fever and vomiting. The abdominal pain was colicky and intermittent; the vomiting was non-bilious and postprandial. There was no history of constipation and the child was passing stool and flatus. He was clinically febrile with a temperature of 40ºC. He had a mildly distended abdomen which was mildly tender, no abdominal masses were palpated and bowel sounds were present. Mucoid soft faeces were noted on digital rectal examination with no rectal masses palpated. The WBC count was 11.2×10^9 /L with a neutrophil count of 5.42×10^3 /µL. An initial abdominal x-ray showed dilated bowel loops, predominantly small bowel with increased bowel wall attenuation (Fig. 1). An abdominal ultrasound was reported with no features of intussusception or free intraperitoneal fluid but was inconclusive of a diagnosis.We inserted a nasogastric tube for decompression and put the child on nil by mouth. In addition, we instituted intravenous fluids, antibiotics and antipyretics. After 6 hours of conservative management, the abdominal distension had subsided, the child had passed stool twice but still had fever and abdominal tenderness that had since worsened, being associated with guarding and rigidity. We performed an explorative laparotomy, as the child had developed clear signs of peritonitis. Intraoperatively, we found matted ileal and ceacal segments of bowel with fibrinous exudates that had concealed a perforated Meckel’s diverticulum and an inflamed appendix. The MD was 2 cm long with a small neck located 60 cm proximal to the ileocecal valve (Fig. 2).

Click to view Figure 1

Click to view Figure 2

We first removed the appendix then proceeded to do a segmental resection of the intestine with the diverticulum and end-to-end anastomosis of the adjacent bowel. The patient fully recovered and was discharged from the clinic. The resected appendix and diverticulum were sent for histology, which confirmed features of appendicitis with luminal suppuration and infiltration of polymorphs. The diverticulum had colonic mucosa, exhibiting features of diverticulitis with inflammation, ulceration and perforation